Computed Tomographic Analysis of Position of Mandibular Canal and Mandibular Foramen in Patients with Mandibular Asymmetry

Introduction

Mandibular osteotomies in facial asymmetry are complicated by the abnormal position and course of inferior alveolar nerve. This manuscript aims to evaluate the possible variations in the preoperative positions of mandibular canal and mandibular foramen in patients with mandibular asymmetry due to condylar hyperplasia or condylar hypoplasia.

Materials & Methods

This study included 15 patients with mandibular asymmetry due to condylar hyperplasia or condylar hypoplasia for which bilateral sagittal split osteotomy (BSSO) was performed as a corrective procedure. The presence/absence and extent of postoperative neurosensory deficiency was recorded subjectively and objectively. The measurements were done using multiplanar reconstruction (MPR) of three-dimensional radiographic imaging and were compared to normal subjects.

Discussion

The results revealed that the mandibular canal was closer to the buccal cortex on the affected side and the inferior border on both sides in the region of second molar in condylar hyperplasia. In condylar hypoplasia, the canal was nearer to the inferior border and the alveolar crest in relation to second and third molars respectively on the affected and contralateral sides.The mandibular foramen was also more superior to the occlusal plane on both sides in both condylar hyperplasia and hypoplasia.

Conclusion

Based on the study outcomes, the authors propose that assessment of the positions of mandibular canal and mandibular foramen is crucial to avoid postoperative neurosensory deficiencies.

Application of machine learning and artificial intelligence in the diagnosis and classification of polycystic ovarian syndrome: a systematic review

Introduction

Polycystic Ovarian Syndrome (PCOS) is the most common endocrinopathy in women of reproductive age and remains widely underdiagnosed leading to significant morbidity. Artificial intelligence (AI) and machine learning (ML) hold promise in improving diagnostics. Thus, we performed a systematic review of literature to identify the utility of AI/ML in the diagnosis or classification of PCOS.

Methods

We applied a search strategy using the following databases MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Web of Science, and the IEEE Xplore Digital Library using relevant keywords. Eligible studies were identified, and results were extracted for their synthesis from inception until January 1, 2022.

Results

135 studies were screened and ultimately, 31 studies were included in this study. Data sources used by the AI/ML interventions included clinical data, electronic health records, and genetic and proteomic data. Ten studies (32%) employed standardized criteria (NIH, Rotterdam, or Revised International PCOS classification), while 17 (55%) used clinical information with/without imaging. The most common AI techniques employed were support vector machine (42% studies), K-nearest neighbor (26%), and regression models (23%) were the commonest AI/ML. Receiver operating curves (ROC) were employed to compare AI/ML with clinical diagnosis. Area under the ROC ranged from 73% to 100% (n=7 studies), diagnostic accuracy from 89% to 100% (n=4 studies), sensitivity from 41% to 100% (n=10 studies), specificity from 75% to 100% (n=10 studies), positive predictive value (PPV) from 68% to 95% (n=4 studies), and negative predictive value (NPV) from 94% to 99% (n=2 studies).

Conclusion

Artificial intelligence and machine learning provide a high diagnostic and classification performance in detecting PCOS, thereby providing an avenue for early diagnosis of this disorder. However, AI-based studies should use standardized PCOS diagnostic criteria to enhance the clinical applicability of AI/ML in PCOS and improve adherence to methodological and reporting guidelines for maximum diagnostic utility.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022295287.

Influence of CoFeB layer thickness on elastic parameters in CoFeB/MgO heterostructures

The surface acoustic waves, i.e., surface phonons may have huge potential for future spintronic devices, if coupled to other waves (e.g., spin waves) or quasiparticles. In order to understand the coupling of acoustic phonons with the spin degree of freedom, especially in magnetic thin film-based heterostructures, one needs to investigate the properties of phonons in those heterostructures. This also allows us to determine the elastic properties of individual magnetic layers and the effective elastic parameters of the whole stacks. Here, we study frequency versus wavevector dispersion of thermally excited SAWs in CoFeB/MgO heterostructures with varying CoFeB thickness by employing Brillouin light spectroscopy. The experimental results are corroborated by finite element method-based simulations. From the best agreement of simulation results with the experiments, we find out the elastic tensor parameters for CoFeB layer. Additionally, we estimate the effective elastic parameters (elastic tensors, Young's modulus, Poisson's ratio) of the whole stacks for varying CoFeB thickness. Interestingly, the simulation results, either considering elastic parameters of individual layers or considering effective elastic parameters of whole stacks, show good agreement with the experimental results. These extracted elastic parameters will be very useful to understand the interaction of phonons with other quasiparticles.

The Thyroid Hormone Axis and Female Reproduction

Thyroid function affects multiple sites of the female hypothalamic-pituitary gonadal (HPG) axis. Disruption of thyroid function has been linked to reproductive dysfunction in women and is associated with menstrual irregularity, infertility, poor pregnancy outcomes, and gynecological conditions such as premature ovarian insufficiency and polycystic ovarian syndrome. Thus, the complex molecular interplay between hormones involved in thyroid and reproductive functions is further compounded by the association of certain common autoimmune states with disorders of the thyroid and the HPG axes. Furthermore, in prepartum and intrapartum states, even relatively minor disruptions have been shown to adversely impact maternal and fetal outcomes, with some differences of opinion in the management of these conditions. In this review, we provide readers with a foundational understanding of the physiology and pathophysiology of thyroid hormone interactions with the female HPG axis. We also share clinical insights into the management of thyroid dysfunction in reproductive-aged women.

LBMON114 Enrichment Of Rare Sequence Variants In Genes That Communicate Metabolic Signals To The GnRH System In Hypothalamic Amenorrhea

Introduction

Functional hypothalamic amenorrhea (HA) is commonly associated with increased exercise or decreased caloric intake and often with stress. We have previously demonstrated an increased burden of rare sequence variants (RSVs) in genes involved in GnRH ontogeny and upstream regulation in women with HA, but the role of metabolic and stress signaling to the GnRH neuronal system is poorly defined in this population.

Methods

The study included 100 women with a confirmed diagnosis of HA. The control cohort consisted of 468 women (aged 45­­-65 years) drawn from the NIH ClinSeq® Project. Exome sequencing was performed on peripheral blood genomic DNA. A subset of 72 genes was analyzed that have been shown to: 1) link metabolic or stress with reproductive phenotypes or 2) integrate metabolic and stress pathways with control of GnRH secretion. Joint genotyping of case and control samples was performed using the GATK GenotypeGVCFs function, locus-filtering using the VariantRecalibrator function, and genotype refinement using CalculateGenotypePosteriors with computation of median depths. Median depth positions <10, positions failing GATK VQSR or GATK genotype quality scores <20 were excluded. RSVs were identified by < 1% frequency in any subpopulation in gnomeAD for all-subjects (AS) and < 1% frequency in non-Finnish Europeans for Caucasians (CS). Data were analyzed for AS and for CS using a one-sided Fisher exact test for metabolism genes and stress genes. An additional regression analysis was conducted on the number of RSVs in a given gene as a predictor of HA vs. control. Comparisons with a p-value of < 0.1 are reported.

Results

HA patients exhibited an increased burden of RSVs in metabolism genes vs. controls (AS p=0. 043; CS p=0.105). The total number of RSVs per gene highlighted differences between HA and controls for the following genes: ADAMTSL1, GRINA, GRIN1, HCRTR1, TENM3, and NOS1 (AS p<0. 001, p=0. 032, p=0. 057, p=0. 082, p=0. 091, p=0. 095; CS p=0. 024, p=0. 044, p=0. 044, p NS, p=0. 086, p NS). Interestingly, RSVs in NOS1 and TENM3 appeared to be protective for HA (odds ratio <1 for both). In contrast, candidate stress genes were not significant in either the AS or CS (p=0.788, p=0.910).

Conclusions

These data suggest that RSVs in genes involved in phenotypes or signaling pathways that link metabolism to GnRH secretion may predispose to development of HA in the setting of decreased energy balance, but not for stress-related genes. GRINA and GRIN1 are important components of glutamate signaling that facilitate both appetite and GnRH secretion either directly or through kisspeptin. HCRTR1 plays a similar role in linking appetite and GnRH secretion while NOS1, which facilitates kisspeptin signaling, may be protective. This work highlights the need for further studies to understand the potential roles of ADAMTSL1 and TENM3 as risk factors for HA.

Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

RF10 | PMON215 Greater changes in metabolic hormones are associated with a smaller decrease in pulsatile LH secretion in response to short term moderate energy restriction in healthy, young women

Background

Energy restriction may result in hypothalamic amenorrhea by inhibiting GnRH secretion and downstream pulsatile LH secretion. Energy restriction also leads to adaptive changes in metabolic hormones. We sought to determine whether metabolic changes in response to energy restriction predict or mitigate inhibition of GnRH secretion.

Methods

Nineteen healthy women, (mean age ± SD; 23.36 ± 2.08 yrs) with regular ovulatory cycles and no evidence of energy restriction or excessive exercise, underwent two 5-day dietary interventions with identical exercise in the early follicular phase of two menstrual cycles. A neutral energy availability (NEA; 45 kCal/kg*LBM/d) was followed by a deficient energy availability (DEA; 20 kCal/kg*LBM/d) diet. On day five of each intervention, body composition was analyzed (BodPod®), and blood was sampled between 0800 —1600 hours for LH, TSH and GH, every 10 min, cortisol every 30 min, T3, reverse T3 (rT3) and T4 every 60 min, free T3 (FT3), free T4 (FT4) and TBG at 0800 h and 1600 h. We correlated means of pulsatile LH pulse frequency (LHPF) with integrated metabolic hormone changes across the day in the subset of women with reduced or unchanged LHPF after DEA (n=10) using linear regression.

Results

In ∼50% of healthy young women, LHPF decreased or was unchanged in response to short-term moderate energy deprivation. BMI and bodyweight declined after DEA in both groups while % fat mass was unchanged. TSH, T3, leptin, insulin declined, and T4 increased from NEA to DEA while glucose, cortisol and GH were unchanged.

In subjects with reduced/unchanged LHPF, % delta T3 correlated inversely with delta LHPF (r=-0.727, p=0.017). Similarly, non-fasting delta TSH correlated inversely with % delta LHPF (r=-0.643, p=0.045), and % delta AUC TSH (r=-0.642, p=0.045) correlated inversely with DEA LHPF.

Percent delta insulin (r= -0.722, p=0.018) and % delta insulin AUC (r= – 0.688, p=0.028) correlated inversely with delta LHPF. Percent delta insulin-glucose ratio (r=-0.772, p=0.009) and % change in AUC insulin-glucose ratio (r=-0.759, p=0.011) also correlated inversely with delta LHPF. This inverse relationship was preserved when insulin was normalized for caloric intake (n-insulin) was correlated with % delta LHPF (r=-0.722, p=0.018) and % delta AUC n-insulin correlated with delta LHPF (r= -0.631 and p= 0.050).

Delta AUC leptin (r=-0.684, p=0.029) and % delta AUC leptin (r=-0.670, p=0.034) also correlated inversely with delta LHPF.

Mean cortisol at NEA correlated inversely with LHPF during DEA (r=-0.816, p=0.007), implying that higher baseline cortisol levels may predict a greater relative fall in LHPF. Cortisol AUC in DEA also correlated inversely with LHPF in DEA (r=-0.722, p=0.028).

Conclusion

Our data suggest that greater changes in metabolic hormones may protect against the inhibitory effect of moderate energy deprivation on GnRH secretion in healthy young women with normal reproductive function.

Presentation: Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m., Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Phosphonomethyl iminodiacetic acid functionalized metal organic framework supported PAN composite beads for selective removal of La(III) from wastewater: Adsorptive performance and column separation studies

The rare earth elements being toxic in nature are being accumulated in water bodies as their industrial usage is growing exponentially, thus their efficient separation holds an immense significance. Herein, ligand functionalized metal organic framework (MOF), Phosphonomethyl iminodiacetic acid coordinated at Fe-BTC, was synthesized post-synthetically and incorporated subsequently in polyacrylonitrile polymer to prepare the composite beads via nonsolvent induced-phase-inversion technique for selective adsorption of La(III) from the wastewater in batch and dynamic column mode. XPS NMR, and FTIR were used to establish the interaction between functionalized ligand and unsaturated metal nodes of MOF. The adsorption capacity was 232.5 mg/g and 77.51 mg/g at 298 K of the functionalized MOF and composite beads respectively. Adsorption kinetics followed a pseudo-second order rate equation, and isotherm indicated the best fitting with Langmuir model. The dynamic behavior of the adsorption column packed with MOF/Polymer beads was fairly described by the Thomas model. The breakthrough time of 23.2 h could be attained with 12 cm of bed height and 10 ml/min of flow rate. These MOF/Polymer beads shown the selectivity of La over transitional metals were recycled over 5 times with about 15% loss of adsorption capacity. The findings provide suggestive insights of the potential use of functionalized MOF towards the separation of the rare earth element.

Survivorship Issues in Adult Patients With Histiocytic Neoplasms

Adult-onset histiocytoses (AOH), primarily Rosai-Dorfman disease (RDD), Erdheim-Chester Disease (ECD), and adult Langerhans cell histiocytosis (ALCH), are a group of related histiocytic neoplastic disorders featuring multisystemic manifestations. The disorders are largely incurable, and are essentially chronic neoplastic diseases with a variable prognosis. Prompt diagnosis and treatment is important to prevent debilitating and even life-threatening complications. Survivorship issues abound in AOH, due to their multisystemic manifestations and the sometimes recalcitrant chronic inflammation, which can lead to other debilitating complications such as fatigue, weakness, and pain. Because these disorders are rare, few healthcare professionals are proficient in their management; therefore the aim of these guidelines is to offer guidance on how to manage patients, and how to create survivorship care plans through the efforts of an interdisciplinary team.

Evidence in crisis: a closer look into the quality of published systematic reviews in the cardiology literature

Background

Systematic reviews are usually considered as the highest level of evidence and are increasingly used in shaping cardiology policies and guidelines. However, as the rate of publishing systematic reviews increases annually, there are rising concerns regarding their quality and reporting standards.

Purpose

The current analysis provides an insight into the quality of published systematic reviews in cardiology and provides recommendations for researchers, clinicians, and stakeholders in this regard.

Methods

Using a comprehensive Medline/PubMed search, we retrieved all systematic reviews, published between 2009 and 2019 in five general cardiology journals with the highest impact factor as per the Clarivate Analytics 2019 Journal Impact Factor List (Circulation, European Heart Journal, Journal of the American College of Cardiology, Circulation Research, and JAMA Cardiology). We assessed the methodological characteristics, eligibility criteria, reporting standards, as well as review quality scores according to the AMSTAR tool.

Results

Among 352 retrieved reviews, 275 (75.3%) performed direct head-to-head analysis and 164 (46.6%) included only clinical trials. The median numbers of searched databases and included studies were 3 (IQR: 2, 3) and 13 (IQR: 7, 30). The primary outcomes were often hard clinical endpoints as mortality (39.2%) and stroke (11.9%). 64 (18.2%) registered their protocol, 208 (58.4%) used validated tools for risk of bias assessment, 177 (52.3%) assessed for publication bias, and 221 (62.8%) adhered to the PRISMA checklist. Thirty-five reviews detected significant publication bias, which was significantly associated with heterogeneity of the primary outcome. The AMSTAR quality scores were low or critically low in 71% of evaluated reviews. Further, 87 (24.7%) did not report on whether they received funding or not, 33 (9.4%) reported receiving no funding, and 232 adequately reported on their funding sources [70 (19.9%) from governmental/academic sources, 120 (34.1%) from pharmaceutical companies, and 42 (11.9%) from both sources]. analysis showed that reviews with advanced statistical analysis, those that included RCTs, adhered to the PRISMA checklist, or had higher AMSTAR quality scores had significantly higher citation metrics (p&lt;0.05).

Conclusion

Due to the widespread low quality and poor reporting in cardiovascular systematic reviews, clinicians should be educated on the value of methodological quality in interpreting systematic review findings. In addition, academic societies and guideline writing groups should implement rigorous critical appraisal and peer review policies to improve the synthesis and utilization of systematic reviews in evidence-based cardiovascular medicine.

Funding Acknowledgement

Type of funding sources: None.

Outcomes of transfemoral-transcatheter aortic valve replacement with Sapien-3 valve in liver cirrhosis patients

Background

Little is known about the outcomes of liver cirrhosis patients with severe aortic stenosis (AS) who undergo transcatheter aortic valve replacement (TAVR).

Methods

We undertook a retrospective analysis of consecutive patients with severe symptomatic AS who underwent transfemoral-TAVR with Sapien-3 valve at our Clinic between April 2015 and December 2018, yielding 32 patients with liver cirrhosis on imaging including ultrasound and/or computed tomography. Their baseline characteristics, procedural and long-term outcomes after TAVR with the non-cirrhotic group were compared, along with their management strategies as per the hepatology team.

Results

Among 1028 patients, 32 were assigned to the cirrhosis, and 996 were assigned to the non-cirrhosis (control) group. Compared with the control group cirrhotic patients were slightly younger in age (74.5 vs 81.2 years), had a slightly higher BMI (31.3 vs 29.3), and had a higher incidence of prior history of myocardial infarction (38% vs 33%). Baseline variables including the history of smoking, hypertension, diabetes, and atrial fibrillation were comparable in both groups. Among cirrhotic patients (n=32), the most common etiologies were non-alcoholic steatohepatitis (NASH) (37.5%), Alcoholism (18.75%), and Hepatitis C (12.5%). The mean MELD-NA score was 11.8 and 67% of patients were Child PUGH Class A and 33% were Child PUGH Class B and all patients had a Child PUGH score of ≥5. 53% of patients (n=17) in the cirrhosis group were evaluated by Hepatology and 12.5% (n=4) were evaluated for a liver transplant but only 1 patient had a liver transplant post-TAVR. Compared with the control group cirrhotic patients had similar 1-year mortality (12% vs 12%, p=1), had a lower rate of 30-day new pacemaker post tavr (6% vs 9% p=0.85), had a higher rate of 1-year readmission for heart failure (12% vs 5% p=0.12) and similar 1-year major adverse cardiac and cerebrovascular event (MACCE) rate (15% vs 14% p=0.98)

Conclusion

Patients with severe AS undergoing TAVR with concomitant liver cirrhosis demonstrate comparable outcomes compared with their non- cirrhotic counterparts. NASH followed by alcoholic cirrhosis was found to be most common etiology.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Abnormal Pituitary Imaging and Associated Endocrine Dysfunctions in Erdheim-Chester Disease

Background: Erdheim Chester disease (ECD) is a rare histiocytic neoplasm associated with hypothalamic and pituitary infiltration and dysfunction. We determined the abnormal pituitary imaging (API) phenotypes in subjects with ECD and analyzed their associated endocrine dysfunctions. Methods: This was a cross-sectional examination of a natural history cohort study of 61 subjects with ECD performed at a tertiary care clinical research center. The diagnosis of ECD was based on clinical, molecular, and histopathological features. Enrolled subjects underwent baseline endocrine tests of anterior and posterior pituitary function in addition to pituitary imaging. The following variables were analyzed- age, sex, body mass index (BMI), BRAF V600E, hsCRP, ESR, pituitary hormone deficit number, diabetes insipidus (DI), and panhypopituitarism. Fisher’s exact test or t-test/Wilcoxon tests compared patients with and without API. Results: Sixty-one subjects with ECD (age ±SD: 54.3 ±10.9, 46 (75.4%) males) were studied. The prevalence of API was 32.8% (n=20), who were younger than those with normal imaging (50.3 ±10.5 vs 56.3 ±10.7 yrs, p=0.042). The most common pituitary imaging abnormalities included thickened pituitary stalk (18.03%, n=11/61), followed by pituitary encasement, small pituitary and abnormal morphology (6.55%, n= 4/61 for each). A higher prevalence of DI (45.0% vs 9.8%, p=0.003) and panhypopituitarism (45.0% vs 4.9%, p&lt;0.001), and a higher number of pituitary deficits (median (IQR): 2.0 (0-2.5) vs 0 (0-1.0), p=0.007) were noted in patients with API compared to those with normal imaging. Other biochemical markers were similar between both groups. Conclusion: Abnormal pituitary imaging was commonly seen in ECD and was also associated with a younger age and hormone deficits suggesting associations with pituitary structure-function.

The Effects of Energy Restriction on Thyroid Hormone Dynamics

Background: Intermittent energy restriction (IER) is gaining popularity as a weight-loss strategy. However, the effect of short-term energy restriction on thyroid hormone dynamics is not well characterized. Methods: Nineteen healthy women age 23.36± 2.08 yr (mean ± SD) with normal baseline thyroid function and negative anti-thyroid antibodies underwent two 5-day interventions of a prescribed diet and identical standardized exercise in the early follicular phase of two menstrual cycles - neutral energy availability (NEA) 45 kCal/kg*LBM/d followed by deficient energy availability (DEA) 20 kCal/kg*LBM/d. Energy requirements were estimated as previously described (doi.org/10.1210/jendso/bvaa046.1468) and were used to generate a diet and exercise regimen for each participant. On day 5 of both interventions, body composition was assessed by BodPod®. Standardized NEA or DEA breakfast and lunch were provided as appropriate as well as a standardized NEA snack on both sampling visits. Blood sampling was performed for 8 hours starting at ~0800 h with measurement of TSH and growth hormone (GH) every 10 min, cortisol every 30 min, total T3 (TT3), reverse T3 (rT3) and total T4 (TT4) every 60 min, free T3 (FT3), free T4 (FT4) and TBG at the beginning and end of sampling. Liquid chromatography-tandem mass spectrometry (LC-MS) was used for measurements of all thyroid hormones, with the exception of TSH and TBG which were measured by ELISA as were GH and cortisol. Data were analyzed using ANOVA-RM and linear mixed models. Results are presented as mean or least squared mean ± sem. Results: Body mass index, bodyweight and % fat mass were not different between interventions. GH and cortisol were unaffected by DEA (p=0.46, p=0.63). TBG was not affected by time of day or dietary intervention (p=0.95, p=0.41). However, compared with NEA, TT3 (89.15 ± 2.89 vs 95.55 ± 2.89 ng/dL for DEA and NEA, respectively; p&lt;0.0001) and TSH (0.92 ± 0.08 vs 1.03 ± 0.09 μIU/mL; p=0.0011) were lower after DEA, while TT4 (6.26 ± 0.25 vs 6.06 ± 0.25 μg/dL; p=0.04), FT4 (3.37 ± 0.26 vs 2.94 ± 0.25 ng/d;, p=0.0052) and rT3 (11.77 ± 0.58 vs 8.85 ± 0.51 ng/dL; p&lt;0.0001) were higher. Regardless of dietary intervention, FT3 (p=0.0005), TT3 (p&lt;0.0001), TT4 (p&lt;0.0001) and TSH (p&lt;0.0001) decreased across the day. Conclusion: Using LC-MS for as a more robust measure of thyroid hormones, we have now shown that changes in thyroid hormone dynamics occur after only 5 days of 55% energy restriction in the absence of alterations in body composition, cortisol, GH, TBG or the circadian pattern of thyroid hormone secretion. The decrease in TSH combined with the decrease in TT3 and increase in rT3 support the contribution of both central and peripheral mechanisms to these changes. Taken together these results provide support for a multi-level adaptation in thyroid hormone dynamics to conserve energy expenditure in response to short-term energy restriction.

Resolution of Abnormal Gonadotropin Secretion After Surgical Cure in Men With ACTH-Dependent Cushing Syndrome

Background: Hypothalamic-pituitary-gonadal (HPG) dysfunction is known to occur in male patients with Cushing Syndrome (CS) but the underlying mechanisms of HPG dysfunction remain unclear. We performed frequent blood sampling and GnRH stimulation tests to assess gonadotropin secretion in males before and after surgical cure of CS. Methods: We evaluated eight males age 32.5±12 years (mean ± SD) enrolled for surgical cure of ACTH-dependent CS at a tertiary care research center. Urinary free cortisol (UFC) was measured before and after surgery. Blood was sampled every 20 minutes for 24-hours with measurement of LH and FSH, before and 2 weeks to 160 weeks (median 80 weeks) after surgery. Patients received 100 μg of gonadotropin releasing hormone (GnRH) iv with measurement of LH and FSH at 0, 10 and 20 min before and 15, 30, 45, 60, 120 and 180 min after administration. Non-normative data was log-transformed before analysis using paired two-tail t-tests. A p-value of &lt;0.05 was considered significant. Gonadotropin values are expressed in U/L as equivalents of the 2nd International Preparation of human menopausal gonadotropins with normal adult male ranges of 6-26 and 5-25 IU/L for LH and FSH, respectively. Results: Mean UFC was elevated ~ 6 times above the upper normal limit before surgery and returned to the reference range after surgery. 24-hour LH rose from 7.82 ± 1.48 preoperatively to 13.07 ± 2.96 IU/L (mean ± sem) after surgery (p=0.026) while mean FSH was unchanged (8.48 ± 1.51 vs 6.92 ± 1.29, p=0.37). LH pulse frequency, a marker of pulsatile GnRH secretion, recovered from a subnormal value of 6.88 ± 0.55 pulses/24 hr before to 12.13 ± 0.72 pulses/24 hr after surgery (p&lt;0.0001) while LH pulse amplitude did not change (6.47 ± 1.21 vs 4.76 ± 0.88 IU/L, p=0.21). In response to GnRH there was a robust increase in LH that was not affected by curative surgery for CS (27.0 ± 7.2 vs 21.2 ± 7.6 IU/L; p=0.14) as was also the case for FSH (3.7 ± 1.2 vs 2.3 ± 0.5 IU/L; p=0.48), consistent with the absence of an effect of CS on gonadotroph responsiveness to LHRH. Conclusion: In men with Cushing Syndrome, hypogonadism is associated with inhibition of endogenous GnRH secretion but preservation of the pituitary response to GnRH. Hypothalamic suppression of the HPG axis is reversible after cure of CS.

The Hypothalamic Pituitary Thyroid Axis and Sleep

Sleep has a bidirectional relationship with the hypothalamic-pituitary-thyroid (HPT) axis, and both these homeostatic processes are inter-dependent for robust physiological functioning. The quality and quantity of sleep influence the circadian pattern of TSH and thyroid hormone secretion. Short term sleep restriction significantly reduces the amplitude of nocturnal TSH secretion and may modulate active thyroid hormone secretion, likely through an increased sympathetic tone. Conversely, TSH and active thyroid hormone affect the quantity and architecture of sleep. For instance, low TSH values are permissive for slow wave sleep and maintenance of normal sleep architecture, while the hypo- or hyper-secretion of active thyroid hormones adversely affects the quality and quantity of sleep. Structural thyroid disorders may also be associated with an altered circadian clock - a phenomenon warranting further investigation. In this review, we aim to provide readers a comprehensive review on the associations between the HPT axis and sleep patterns.

The Hypothalamic-Pituitary-Thyroid Axis in Cushing Syndrome Before and After Curative Surgery

BACKGROUND

We do not fully understand how hypercortisolism causes central hypothyroidism or what factors influence recovery of the hypothalamic-pituitary-thyroid axis. We evaluated thyroid function during and after cure of Cushing syndrome (CS).

METHODS

We performed a retrospective cohort study of adult patients with CS seen from 2005 to 2018 (cohort 1, c1, n = 68) or 1985 to 1994 (cohort 2, c2, n = 55) at a clinical research center. Urine (UFC) and diurnal serum cortisol (F: ~8 am and ~midnight [pm]), morning 3,5,3'-triiodothyronine (T3), free thyroxine (FT4), and thyrotropin (TSH) (c1) or hourly TSH from 1500 to 1900 h (day) and 2400 to 04000 h (night) (c2), were measured before and after curative surgery.

RESULTS

While hypercortisolemic, 53% of c1 had central hypothyroidism (low/low normal FT4 + unelevated TSH). Of those followed long term, 31% and 44% had initially subnormal FT4 and T3, respectively, which normalized 6 to 12 months after cure. Hypogonadism was more frequent in hypothyroid (69%) compared to euthyroid (13%) patients. Duration of symptoms, morning and midnight F, adrenocorticotropin, and UFC were inversely related to TSH, FT4, and/or T3 levels (r = -0.24 to -0.52, P < .001 to 0.02). In c2, the nocturnal surge of TSH (mIU/L) was subnormal before (day 1.00 ± 0.04 vs night 1.08 ± 0.05, P = .3) and normal at a mean of 8 months after cure (day 1.30 ± 0.14 vs night 2.17 ± 0.27, P = .01). UFC greater than or equal to 1000 μg/day was an independent adverse prognostic marker of time to thyroid hormone recovery.

CONCLUSIONS

Abnormal thyroid function, likely mediated by subnormal nocturnal TSH, is prevalent in Cushing syndrome and is reversible after cure.

Scoping review of COVID-19-related systematic reviews and meta-analyses: can we really have confidence in their results?

Aim

The aim of this study was to systematically appraise the quality of a sample of COVID-19-related systematic reviews (SRs) and discuss internal validity threats affecting the COVID-19 body of evidence.

Design

We conducted a scoping review of the literature. SRs with or without meta-analysis (MA) that evaluated clinical data, outcomes or treatments for patients with COVID-19 were included.

Main outcome measures

We extracted quality characteristics guided by A Measurement Tool to Assess Systematic Reviews-2 to calculate a qualitative score. Complementary evaluation of the most prominent published limitations affecting the COVID-19 body of evidence was performed.

Results

A total of 63 SRs were included. The majority were judged as a critically low methodological quality. Most of the studies were not guided by a pre-established protocol (39, 62%). More than half (39, 62%) failed to address risk of bias when interpreting their results. A comprehensive literature search strategy was reported in most SRs (54, 86%). Appropriate use of statistical methods was evident in nearly all SRs with MAs (39, 95%). Only 16 (33%) studies recognised heterogeneity in the definition of severe COVID-19 as a limitation of the study, and 15 (24%) recognised repeated patient populations as a limitation.

Conclusion

The methodological and reporting quality of current COVID-19 SR is far from optimal. In addition, most of the current SRs fail to address relevant threats to their internal validity, including repeated patients and heterogeneity in the definition of severe COVID-19. Adherence to proper study design and peer-review practices must remain to mitigate current limitations.

Insights into the Immunopathophysiology of Severe COVID-19 in Metabolic Disorders

COVID-19 has affected millions of people across the world but disproportionately and severely affects persons with metabolic disorders such as obesity, diabetes mellitus and hypertension. In this brief review, we discuss the pathways of immune dysregulation that may lead to severe COVID-19 in persons with metabolic conditions.

Prevalence of Hypothyroidism in Patients With Erdheim-Chester Disease

IMPORTANCE

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis affecting multiple organs and commonly caused by somatic pathogenic variants in BRAF V600E and mitogen-activated protein kinase genes. Clinical features of ECD result from histiocytic involvement of various tissues; while endocrine involvement in ECD occurs frequently, the prevalence of central or primary hypothyroidism has not been thoroughly investigated.

OBJECTIVE

To assess hypothalamus-pituitary-thyroid (HPT) dysfunction in patients with ECD.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 61 patients with ECD who were enrolled in a natural history study at a tertiary care center between January 2011 and December 2018. ECD was diagnosed on the basis of clinical, genetic, and histopathological features. Data were analyzed in March 2020.

EXPOSURE

Diagnosis of ECD.

MAIN OUTCOMES AND MEASURES

Main outcome was the prevalence of thyroid dysfunction in adults with ECD compared with community estimates. Patients underwent baseline evaluation with a thyroid function test, including thyrotropin, free thyroxine (fT4), and total thyroxine (T4), and sellar imaging with magnetic resonance imaging or computed tomography scan. The association of HPT dysfunction was assessed for differences in age, sex, body mass index, BRAF V600E status, high sensitivity C-reactive protein level, sellar imaging, and pituitary hormonal dysfunction.

RESULTS

A total of 61 patients with ECD (46 [75%] men; mean [SD] age, 54.3 [10.9] years) were evaluated. Seventeen patients (28%) had hypothyroidism requiring levothyroxine therapy. The prevalence of both central and primary hypothyroidism were higher than community estimates (central hypothyroidism: 9.8% vs 0.1%; odds ratio, 109.0; 95% CI, 37.4-260.6; P < .001; primary hypothyroidism: 18.0% vs 4.7%; OR, 4.4; 95% CI, 2.1-8.7; P < .001). Patients with hypothyroidism (both primary and central), compared with patients with euthyroidism, had higher body mass index (median [interquartile range] 31.4 [28.3-38.3] vs 26.7 [24.4-31.9]; P = .004) and a higher prevalence of panhypopituitarism (7 [47%] vs 3 [7%]; P < .001). Among patients with hypothyroidism, those with central hypothyroidism, compared with patients with primary hypothyroidism, had a lower mean (SD) body mass index (28.3 [2.6] vs 36.3 [5.9]; P = .007) and higher frequencies of abnormal sellar imaging (5 [83%] vs 3 [27%]; P = .050) and panhypopituitarism (5 [83%] vs 3 [27%]; P = .050).

CONCLUSIONS AND RELEVANCE

In this cohort study, a higher prevalence of central and primary hypothyroidism was identified in patients with ECD compared with the community. There should be a low threshold for testing for hypothyroidism in patients with ECD, and treatment should follow standard guidelines.

Prevalence of Diabetes and Hypertension and Their Associated Risks for Poor Outcomes in Covid-19 Patients

Coronavirus disease 2019 (Covid-19) has affected millions of people and may disproportionately affect those with hypertension and diabetes. Because of inadequate methods in published systematic reviews, the prevalence of diabetes and hypertension and associated risks of poor outcomes in Covid-19 patients are unknown. We searched databases from December 1, 2019, to April 6, 2020, and selected observational peer-reviewed studies in English of patients with Covid-19. Independent reviewers extracted data on study participants, interventions, and outcomes and assessed risk of bias, and the certainty of evidence. We included 65 (15 794 participants) observational studies at moderate to high risk of bias. Overall prevalence of diabetes and hypertension was 12% (95% confidence interval [CI], 10-15; n = 12 870; I 2: 89%), and 17% (95% CI, 13-22; n = 12 709; I 2: 95%), respectively. In severe Covid-19, the prevalence of diabetes and hypertension were 18% (95% CI, 16-20; n = 1099; I 2: 0%) and 32% (95% CI, 16-54; n = 1078; I 2: 63%), respectively. Unadjusted relative risk for intensive care unit admission and mortality were 1.96 (95% CI, 1.19-3.22; n = 8890; I 2: 80%; P = .008) and 2.78 (95% CI, 1.39-5.58; n = 2058; I 2: 75%; P = .0004) for diabetics; and 2.95 (95% CI, 2.18-3.99; n = 1737; I 2: 0%; P < .001) and 2.39 (95% CI, 1.54-3.73; n = 3107; I 2: 66%; P < .001) for hypertensives. Neither diabetes (1.50; 95% CI, 0.90-2.50; n = 1991; I 2: 74%; P = .119) nor hypertension (1.48; 95% CI, 0.99-2.23; n = 2023; I 2: 69%; P = .058) was associated with severe Covid-19. In conclusion, the risk of intensive care unit admission and mortality for patients with diabetes or hypertension who developed Covid-19 is increased compared with those without these comorbidities.

PROSPERO REGISTRATION NUMBER

CRD42020176582.

Doege-Potter syndrome presenting as 'end-stage renal disease-associated hypoglycaemia': a primary presentation of retroperitoneal sarcoma

A middle-aged woman with end-stage renal disease (ESRD) due to obstructive nephropathy presented to the hospital for an episode of unresponsiveness and hypoglycaemia. Initially, she was diagnosed with hypoglycaemia associated with ESRD and was discharged. However, she returned to the hospital after experiencing tonic-clonic seizures and recurrent hypoglycaemia. Her hypoglycaemia workup revealed an elevated insulin-like growth factor 2 (IGF2) to IGF1 ratio consistent with paraneoplastic IGF2 secretion. Subsequently, a CT abdomen revealed a retroperitoneal mass, found to be a retroperitoneal sarcoma. Her hypoglycaemia was treated with glucocorticoids and growth hormone. Surgical debulking of her tumour was attempted, but she expired due to postoperative haemorrhagic shock. Doege-Potter syndrome is a rare cause of hypoglycaemia which should be suspected in any new-onset, worsening, inexplicable or refractory hypoglycaemia, particularly in non-diabetic ESRD. Here we present a report of retroperitoneal sarcoma presenting with hypoglycaemia in a patient with ESRD without diabetes.

Curative resection of an aldosteronoma causing primary aldosteronism in the second trimester of pregnancy

SUMMARY

A 29-year-old primigravida woman with a known history of primary aldosteronism due to a right aldosteronoma presented with uncontrolled hypertension at 5 weeks of estimated gestation of a spontaneous pregnancy. Her hypertension was inadequately controlled with pharmacotherapy which lead to the consideration of surgical management for her primary aldosteronism. She underwent curative right unilateral adrenalectomy at 19 weeks of estimated gestational age. The procedure was uncomplicated, and her blood pressure normalized post-operatively. She did, however, have a preterm delivery by cesarean section due to intrauterine growth retardation with good neonatal outcome. She is normotensive to date.

LEARNING POINTS

Primary aldosteronism is the most common etiology of secondary hypertension with an estimated prevalence of 5-10% in the hypertensive population. It is important to recognize the subtypes of primary aldosteronism given that certain forms can be treated surgically. Hypertension in pregnancy is associated with significantly higher maternal and fetal complications. Data regarding the treatment of primary aldosteronism in pregnancy are limited. Adrenalectomy can be considered during the second trimester of pregnancy if medical therapy fails to adequately control hypertension from primary aldosteronism.

A Novel Antigonadotropic Role of Thyroid Stimulating Hormone on Leydig Cell-Derived Mouse Leydig Tumor Cells-1 Line

Subclinical hypothyroid men characterized by a rise in only thyroid stimulating hormone (TSH) levels and normal thyroid hormone levels showed a fall in their serum progesterone and testosterone levels. This suggested a role of TSH in regulating Leydig cell steroidogenesis. Therefore, we investigated the direct role of TSH on steroid production and secretion using a mouse Leydig tumour cell line, MLTC-1. MLTC-1 cells were treated with different doses of TSH isolated from porcine pituitary as well as recombinant TSH. Steroid secretion was measured by radioimmunoassay. The mRNA levels of steroidogenic enzymes were quantitated by real time PCR whereas the corresponding protein levels were determined by Western blot. In MLTC-1 cells, pituitary TSH as well as recombinant TSH inhibited progesterone and testosterone secretion in a dose dependent manner. The inhibitory action of TSH on steroid secretion was unique and not mimicked by other anterior pituitary hormones including FSH and ACTH. Recombinant TSH showed no effect on StAR and CYP11A1, the enzymes catalysing the non-steroidogenic and steroidogenic rate-limiting steps of steroid synthesis respectively. Recombinant TSH was shown to inhibit steroidogenesis in MLTC-1 cells by inhibiting the 3β hydroxy steroid dehydrogenase mRNA and protein levels, the enzyme that catalyses the conversion of pregnenolone to progesterone. This inhibitory effect of TSH is probably direct as both mRNA and protein of the TSH receptor were shown to be present in the MLTC-1 cells.

Endocrine Conditions and COVID-19

COVID-19 was declared a global pandemic by the WHO and has affected millions of patients around the world. COVID-19 disproportionately affects persons with endocrine conditions, thus putting them at an increased risk for severe disease. We discuss the mechanisms that place persons with endocrine conditions at an additional risk for severe COVID-19 and review the evidence. We also suggest precautions and management of endocrine conditions in the setting of global curfews being imposed and offer practical tips for uninterrupted endocrine care.

SAT-449 Factors Associated with Reduced Thyroid Hormones in Cushing Syndrome Patients Before and After Surgical Cure

Background: Hypercortisolemia adversely affects thyroid hormone secretion. We previously described the temporal pattern of thyroid function recovery in 23 patients (1). However, the factors leading to suppression and recovery of the hypothalamic-pituitary-thyroid (HPT) axis in Cushing’s syndrome (CS) are not fully understood. We performed two separate studies to investigate these factors. Methods: In study 1, we examined patients (pts, n=62) with CS who underwent curative surgery and recorded their serum morning and evening cortisol, ACTH, tumor volume and duration of symptoms and 24-hour urine free cortisol (UFC) at baseline and the morning serum free T4, TSH and T3 at six-month intervals after cure. Data were log-transformed and Pearson correlations were performed. Linear mixed models were used to study factors that predict recovery of thyroid function. In study 2, we examined the diurnal variation of TSH by performing hourly TSH measurement between 3—7 PM and 12—4 AM on a cohort of pts (n=45) before surgery. Wilcoxon Signed-Rank method was used for comparisons of mean TSH across time and Pearson correlations were performed on log-transformed data. P values <.05 were considered significant. Results: Study 1: In this larger cohort, we confirmed previous findings of suppressed or low normal fT4 and TSH values with active hypercortisolism, with normalization after cure that reflected changes in the T3:TSH, fT4:TSH and T3:fT4 ratios. There were inverse linear correlations between log10 UFC, serum AM and PM cortisol; and log10 TT3, fT4 and TSH before surgery. Independent negative prognosticators of circulating fT4 recovery included UFC greater than 1000mcg/day (nl: 3.5—45mcg/day), duration of symptoms of less than one year, and ACTH levels greater than 60pg/mL(nl: 5—45pg/mL) Study 2: The nocturnal (12 - 4AM) TSH surge was reduced, so that the difference in day and night TSH values was not statistically significant; this contrasts with the 30—50% nocturnal TSH increase above daytime values seen in healthy subjects. There was an inverse relationship between UFC and nocturnal TSH, daytime TSH and TBG values, but there was no direct relationship between UFC and percent changes in nocturnal TSH values. Conclusions: Our findings suggest that a deficit in TSH stimulation of the thyroid gland may explain the reduction in T3 and T4 levels. There is a dose-response relationship between various measures of hypercortisolemia and both thyroid hormones and the pattern of TSH secretion. Finally, the severity of hypercortisolism correlates with a longer time to recovery of the HPT axis in pts with CS after curative surgery. 1. Shekhar S et al. HPG and HPT Axes in Cushing Syndrome. J Endocr Soc, 3 S1, April May 2019

SUN-542 The Effect of Energy Deprivation on Metabolic Hormone Responses to Meals

Background: Intermittent caloric restriction (ICR) has recently gained popularity as a weight-loss strategy; however, fasting metabolic hormones and dynamic meal-related responses, are not well-established in this setting. Methods: We measured metabolic hormone responses to 5-days of neutral or decreased energy availability (NEA, 45 kcal/kg LBM*d vs DEA, 20 kcal/kg LBM*d) in the early follicular phase (EFP) in 19 regularly-cycling, sedentary, women (age 23.36± 2.08 yr; mean±SD). Hunger was assessed using a visual analogue scale on the 5th day of each condition. Scheduled breakfast and lunch were administered according to assigned caloric intake, while an afternoon snack based on NEA was provided on both occasions. Blood was sampled for leptin, insulin, glucose, and GH at 10-min intervals and cortisol was measured at 30-min intervals over eight hours starting at 0800 h, while Orexin A and adiponectin were measured in fasting samples. AUC for each hormone for every meal and diet condition were analyzed using linear mixed models. Insulin and insulin/glucose ratio (I/G) were also adjusted for meal calories. Percentage body fat mass was measured every visit using air displacement plethysmography (BodPod®). Results are presented as least square mean ± sem. Results: There were no differences in body mass index or % fat mass after NEA vs DEA although there was a significant increase in hunger with DEA (p=0.002). Fasting levels of glucose and insulin were unchanged while leptin decreased with DEA (1.27±0.07 and 1.04±0.07 ng/mL, NEA and DEA respectively; p&lt;0.0001), and Orexin A increased (0.55±0.04 and 0.60±0.04 ng/mL; p=0.04). The AUC for glucose was lower with DEA across all meals (p&lt;0.0001). Insulin, I/G and I/G normalized for ingested calories (nI/G) decreased in response to DEA (p&lt;0.005, p&lt;0.05 and p&lt;0.0001). The slope of the increase in leptin across the day was not different between NEA and DEA (p=0.20). Adiponectin, GH and cortisol were unaffected by DEA. Conclusion: These studies indicate that although fasting glucose and insulin are unaffected by short-term caloric restriction, the insulin response to glucose is attenuated even when adjusting for meal-related calories. Orexin A increased and leptin decreased with reduced caloric intake, acting, at least in part, to stimulate appetite. Taken together, these hormonal responses, directed at preserving energy homeostasis, have important implications for understanding the potential efficacy of intermittent caloric restriction.

Valorisation of waste galvanizing dross: Emphasis on recovery of zinc with zero effluent strategy

Galvanizing dross-a waste product from steel industries but it can be a potential secondary resource for zinc through urban mining and recycling. In this concern, a novel and scalable recycling route with zero effluent strategy is developed for the recovery of zinc from galvanizing dross as high grade zinc salts along with value-added products through hydrometallurgical processing. In particular, as-such dross block was leached in 9% (v/v) sulphuric acid medium, wherein strong hydrogen gas effervescence results in alleviating the pulverization and stirring requirements; which are material and energy intensive. Leached zinc is purified and recovered as high purity ZnSO₄.(H₂O/7H₂O) and Zn₃(PO₄)₂.4H₂O through controlled crystallization and phosphate precipitation respectively; which find application in fertilizers and anti-corrosive paints. Temperature difference method was opted for the crystallization of zinc sulfate salts, wherein 70 °C and 30 °C were found to be stability range of crystallization of ZnSO₄.H₂O and ZnSO₄.7H₂O respectively. ZnSO₄-H₂O phase diagram is developed using Factsage calculations to corroborate crystallization study. Moreover, exhaustive thermodynamic analysis of Zn²⁺-PO₄^3--H₂O system at 303 K on precipitation of zinc phosphate using di-ammonium hydrogen phosphate (80-240 g/L) is conducted and the results reveal that with increasing pH (3-6), intermediate hydrogen phosphate species (H₃PO₄, H₂PO₄^- and H₂PO₄^2-) decompose to produce stable PO₄^3- ions leading to zinc phosphate precipitation. Impurity like Iron and supernatant solution left after crystallization are recovered as hydrated iron-calcium sulfate mixture and ammonium sulfate salt respectively. This explored route is economical and easily adaptable with zero effluents, therefore, transcends serious challenges in terms of energy requirement, scale-up and effluent generation.

Adrenocortical carcinoma and pulmonary embolism from tumoral extension

SUMMARY

Adrenococortical carcinoma (ACC) is a rare cancer, occurring at the rate of one case in two million person years. Cushing syndrome or a mixed picture of excess androgen and glucocorticoid production are the most common presentations of ACC. Other uncommon presentations include abdominal pain and adrenal incidentalomas. In the present report, a 71-year-old male presented with abdominal pain and was eventually diagnosed with ACC. He was found to have pulmonary thromboembolism following an investigation for hypoxemia, with the tumor thrombus extending upto the right atrium. This interesting case represents the unique presentation of a rare tumor, which if detected late or left untreated is associated with poor outcomes, highlighting the need for a low index of suspicion for ACC when similar presentations are encountered in clinical practice.

LEARNING POINTS

ACC is a rare but aggressive tumor. ACC commonly presents with rapid onset of hypercortisolism, combined hyperandrogenism and hypercortisolism, or uncommonly with compressive symptoms. Clinicians should have a low index of suspicion for ACC in patients presenting with rapid onset of symptoms related to hypercortisolism and/or hyperandrogenism. Venous thromboembolism and extension of the tumor thrombus to the right side of the heart is a very rare but serious complication of ACC that clinicans should be wary of. The increased risk of venous thromboembolism in ACC could be explained by direct tumor invasion, tumor thrombi or hypercoagulability secondary to hypercortisolism. Early diagnosis and prompt treatment can improve the long-term survival of patients with ACC.

Monitoring and automatic tuning and stabilization of a 2×2 MZI optical switch for large-scale WDM switch networks

Large-scale optical switch networks employ wavelength division multiplexing to expand and facilitate multiple input and outputs. Such networks can be implemented with the Mach-Zehnder interferometer (MZI) as the building block. A fully-loaded MZI switch, meaning one with two optical signals at its two inputs and one that is capable of simultaneously switching those inputs to its two outputs, reduces the number building blocks within the network, and as a result makes them more power and area efficient. However, for practical operation, such MZI switches need to be automatically controlled for overcoming fabrication and thermal variations. We present an interference-based monitoring method that enables automatically switching, tuning, and stabilizing of a fully-loaded 2×2 MZI optical switch and demonstrate a prototype on an SOI platform. Using the proposed device and off-the-shelf electronics, we demonstrate automatic tuning and stabilization of an MZI switch with 12.5 Gb/s and 25 Gb/s data rates and channel spacing as small as 1 nm.

SAT-459 Hypothalamic-Pituitary-Gonadal (HPG) and Hypothalamic-Pituitary-Thyroid (HPT) Axes in Cushing Syndrome (CS): A Retrospective Cohort Study

Background: It is well known that persistent hypercortisolemia suppresses thyroid and gonadal function. However, there are few data on the degree and type of derangement or the course of recovery of these axes after cure. To investigate this, we studied the pre- and post-surgical characteristics of the gonadal and thyroid axis hormones in CS patients (pts). Methods: We retrospectively reviewed records of 23 adult CS pts admitted to our protocols from 2010 - 2018 who received curative surgery with follow-up for 6 - 12 months (6M-12M). We recorded morning serum free T4 (fT4) and TSH, and morning LH, FSH, estradiol (E, premenopausal only) or testosterone (T, in men only) values before (0M), and 6M and 12M after definitive surgery. The rate of abnormal values was calculated at each timepoint. Data were analyzed using SPSS 23 software and are shown as percentage, mean ± SD or median(Interquartile Range). Results: Pt age was 45.6 ± 10.8 years; 21 (91%) were female. Before surgery fT4 (Nl: 0.9 - 1.7ng/dL) and TSH (Nl: 0.27 - 4.2mcIU/mL) were low normal. Subnormal values were seen for LH (13%), FSH (9.5%), E (14.2%, Nl: 15 - 350 pg/mL) and T (100%, n=2, Nl: 181-758ng/dL). fT4 increased from 0.96 ± 0.2 at 0M to 1.12 ± 0.13 at 12M (p=0.016), remaining in the lower half of the normal range. TSH increased significantly from 0M (0.98 ± 0.57) to 6M (2.8 ± 1.4) and 12M (2.9 ± 0.13) (p<0.0005 for both). In premenopausal women (n=14), there was a statistically significant (SS) change from 0M to 12M in both serum E (38.9 pg/mL (21.4 - 51) to 132.3 pg/mL (84.2 - 388), p=0.028) and LH levels (2.9 U/L (3.3 - 5.9) to 7.5 (3.6 - 13.6), nl(follicular phase): 1-12 U/L, p=0.019); the change in E, LH and FSH at 6M and in FSH at 12M was not SS. Menses were documented only in 8; resumption of normal cycles occurred 2 - 11 months after surgery. In postmenopausal females(n=7) there were no SS changes in LH or FSH from OM (LH: 21.4+11.1, nl: 11-40 U/L; FSH 54.3+30.5, nl: 22-153 U/L) to 6M or 12M. One man was taking T at 0M and one had a low T level at 0M (88.2 ng/dL) that normalized (357 ng/dL, nl: 181 - 758ng/dL ) at 6M.Conclusions: HPT and HPG axes improved after cure. While the HPT axis may start recovery at 6M, reflected by SS rise in TSH at 6M, HPG axis recovery was more homogeneous. Larger studies are needed to uncover the effects of hypercortisolemia on Hypothalamic-Pituitary-End organ axes and timelines of their recovery after treatment.

SUN-438 Spontaneous Recovery of the Hypothalamic-Pituitary-Gonadal (HPG) Axis in a Female with Kallmann Syndrome

Background: Kallmann Syndrome (KS) is characterized by hypogonadotropic hypogonadism (HH) due to isolated GnRH deficiency (IGD) and anosmia. While reversal of KS has been described, predominantly in males, few cases have been described in females. We report a female with KS who demonstrated spontaneous recovery of her HPG axis. Case Report: A 34-year-old woman with a history of KS was referred to the NIH Clinical Center for evaluation. She was evaluated for absent thelarche and primary amenorrhea at age 18 when, due to her history of vigorous exercise and low BMI, she was assumed to have hypothalamic amenorrhea. At age 22, she was first noted to be anosmic by her endocrinologist who diagnosed her with KS. She underwent bilateral breast augmentation, and oral contraceptive pills (OCPs) induced regular menstrual bleeding. OCPs were self-discontinued after 1 year and amenorrhea recurred. By her late 20s, her level of exercise had decreased and her BMI normalized. She reported 3 episodes of spontaneous menstrual spotting in the six months preceding her visit, cyclical but irregular breast tenderness and emotional lability in the absence of hormonal treatment. Her medications included only fluoxetine. Physical examination revealed a BMI of 19.1 kg/m2, bilateral breast implants, a high-arched palate and bilateral fifth digit clinodactyly. Her laboratory evaluation revealed a serum LH of 8 U/L, FSH of 9 U/L and E₂ of 19 pg/mL; all other anterior pituitary hormones were normal. Frequent blood sampling revealed a high-frequency pattern of LH pulsatility (24 pulses/24 hrs) with sleep augmentation and mean LH of 6.8 U/L. Formal smell testing confirmed anosmia. Her pelvic ultrasound revealed normal ovaries with follicles and normal uterus with a 4 mm endometrial stripe. A brain MRI was normal except for absent olfactory bulbs. Clinical testing of 14 IGD genes showed a novel heterozygous ANOS1 variant (c.298C>A p.Q100K) of unknown significance that was also present in her unaffected mother. A maternal half-uncle was reportedly anosmic but is now deceased. Discussion: This KS female exhibited spontaneous recovery of her HPG axis, which has been reported in very few cases. Her olfactory bulb aplasia is consistent with a congenital defect in GnRH neuronal development given their common ontogeny, suggesting that her HH and recovery were not simply due to changes in body weight nor exercise. Although females with heterozygous ANOS1 variants have been reported to demonstrate features of HH, the role of this novel ANOS1 variant remains unclear due lack of functional data and the presence of the same variant in her asymptomatic mother. Conclusions: Reversal of the reproductive phenotype in women with KS is rare with little known about their genetic abnormalities and long-term outcomes. Further study of such cases is warranted to gain insight into the mechanisms required for activation of the HPG axis.

MON-605 Hypothyroidism in Erdheim-Chester Disease: Experience from a Tertiary Care National Referral Center

Background: Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis affecting multiple organs, including the endocrine system. While endocrine involvement in ECD is well characterized, infiltration of the hypothalamic-pituitary-thyroid axis may cause either primary or central hypothyroidism that is often underdiagnosed. The prevalence of hypothyroidism and the occurrence of isolated central hypothyroidism in ECD has not been thoroughly investigated. Methods: A prospective cohort study of biopsy-confirmed cases of ECD was conducted at the National Institutes of Health. Clinical, radiographic, and biochemical characteristics were assessed. All subjects underwent baseline evaluation with a thyroid function test, including TSH, free thyroxine (fT4) and total thyroxine (T4).Results: Sixty-one subjects with ECD (46 males, 54.3 ± 10.8 years) were evaluated. Sixteen subjects (26%) hadprimary hypothyroidism and were receiving thyroid hormone supplementation before enrollment, with a mean TSH 2.00 ±1.63 mcIU/mL (normal 0.27-4.20 mcIU/mL), fT4 1.52 ±1.51 ng/dL (normal 0.9-1.7 ng/dL), and T4 7.42 ±2.15 mcg/dL (normal 4.5-11.7 mcg/dL). The prevalence of primary hypothyroidism was higher than general population estimates (26% vs. 3.7%, P<0.05). No subject presented with myxedema coma or thyrotoxicosis. One subject (1.6%), a 61-year-old Caucasian female with ECD-related cerebellar dysfunction, retroperitoneal fibrosis, and osteosclerosis, harbored the BRAF V600E pathogenic variant and had a biochemical pattern suggestive of isolated central hypothyroidism: TSH 0.16 mcIU/mL, fT4 1.2 ng/dL and a normal baseline pituitary function test. She did not report symptoms suggestive of clinical thyroid disease and her physical examination was unremarkable. Pituitary MRI showed a small hypoenhancing lesion in the posterior aspect of the pituitary gland that is clinically insignificant. Dynamic TSH-secretion testing with a thyrotropin releasing hormone (200 μg IV synthetic TRH with serial TSH testing) demonstrated a blunted response in keeping with central hypothyroidism; baseline TSH 0.35 mcIU/mL, peak 2.90 mcIU/mL (ΔTSH <7 mcIU/mL). Conclusion: The prevalence of hypothyroidism (1 in 4) is high in subjects with ECD. Clinicians should have a low threshold to screen for hypothyroidism in this at-risk population. Central hypothyroidism is a rare manifestation of ECD and should be suspected in the setting of pituitary disease with a fT4 level below the laboratory reference range or low-normal levels in conjunction with a low, normal, or mildly elevated TSH.

SUN-377 Adrenal Incidentaloma Evaluation in Critical Illness: A Diagnostic Dilemma

Background: Adrenal incidentalomas (AIs) are a “disease of modern technology” with a prevalence of ~5%, expected to increase as imaging modalities become more sensitive and widely available. While the majority of AIs are benign, ~15% are malignant or associated with hormone over secretion, thus all AIs require prompt investigation. The recommended diagnostic testing for AIs is validated in healthy outpatient subjects, with no established algorithm for the inpatient/critical illness setting. Clinical Case: A 66 year-old male with hypertension and type 2 DM, recent myocardial infarction, presented in cardiogenic shock. His course was complicated by an episode of cardiac arrest with successful resuscitation. Due to inotrope and intra-aortic balloon pump dependency, he was urgently evaluated for left ventricular assist device (LVAD). A non-contrast abdominal CT obtained during pre-LVAD workup, showed a 2.4 x 1.9 cm right adrenal nodule of indeterminate density. The review of systems was positive for erectile dysfunction, and negative for easy bruising, facial plethora, fractures, proximal muscle weakness or weight changes. Physical examination revealed absence of Cushingoid features. Laboratory testing showed an abnormal overnight 1mg dexamethasone suppression test (DST) (12.1 mcg/dL , n: < 1.8 mcg/dL), elevated ACTH (75pg/mL, n: 7-69pg/mL), elevated AM serum cortisol (40.7 mcg/dL, n: 5-23 mcg/dL), elevated PM serum cortisol (21.7 mcg/dL, n: 3-15 mcg/dL). He had normal 24-hour urinary free cortisol, serum DHEAS, plasma renin activity and aldosterone concentration. Repeat adrenal CT scan showed a 1.6 x 1.9 cm R adrenal nodule, non-contrast density 33 HU, venous phase 99 HU and delayed phase 55 HU (washout 45%) concerning for pheochromocytoma. However, plasma and urine metanephrines and catecholamines were normal. The absence of Cushingoid features and evidence of ACTH dependent hypercortisolism with normal diurnal variation (despite an abnormal DST) ruled out Cushing’s syndrome, and the patient successfully underwent LVAD surgery. A literature review revealed only 2 AI cases evaluated during critical illness. While both cases had an abnormal DST without normal diurnal variation, only one case had similar ACTH dependent hypercortisolemia. Conclusion: This case illustrates the dilemma surrounding the evaluation of AIs in the setting of critical illness, the lack of inpatient/critical illness specific guidelines and the importance of clinical assessment. Furthermore, it suggests a possible diagnostic approach that can be considered in similar clinical situations.

Quality of Life in Patients with Coronary Artery Disease and Panic Disorder: A Comparative Study

OBJECTIVES

The quality of life (QOL) of patients with coronary artery disease (CAD) is known to be impaired. Non-cardiac chest pain referrals are often under-diagnosed and untreated, and there are hardly any studies comparing the QOL of CAD and panic disorder related (non-cardiac) chest pain referrals (PDRC).

METHODS

We assessed the psychiatric morbidity and QOL of patients newly diagnosed with CAD (n = 40) at baseline and six weeks post-treatment and compared their QOL with patients with PDRC (n = 40) and age- and gender-matched healthy controls (n = 57). Psychiatric morbidity in the CAD group was assessed using the General Health Questionnaire (GHQ12) item, Hamilton Anxiety Scores (HAM-A), and Hamilton Depression Scores (HAMD). QOL measures were determined by the World Health Organization QOL questionnaire (brief) and Seattle Angina Questionnaire. The CAD group was treated with anti-ischemic drugs (nitrates, betablockers), antiplatelet drugs (acetylsalicylsalicylic acid), anticoagulants (low molecular weight heparin, clopidogrel), and managed for risk factors. The PDRC group was treated with selective serotonin reuptake inhibitors and anxiolytics.

RESULTS

Patients with panic disorder had a worse QOL than those with CAD and healthy controls in the physical domain and psychological domain (PDRC vs. CAD vs. healthy controls, p < 0.001). In the CAD group, smoking was associated with change in angina stability (p = 0.049) whereas other tobacco products were associated with change in angina frequency (p = 0.044). Psychiatric morbidity was present in 40.0% of patients with CAD. In the PDRC group, a significant correlation of HAM-A scores was noted in the physical (p = 0.000), psychological (p = 0.001), social (p = 0.006), and environment (p = 0.001) domains of QOL. Patients with panic disorder had a significant improvement in anxiety scores after treatment compared to baseline (HAM-A scores difference 21.0 [16.5-25.6]; p < 0.001).

CONCLUSIONS

Patients in the PDRC group had a worse QOL than those in the CAD and healthy control groups. This highlights the need for careful diagnosis and prompt treatment of panic disorder in these patients to improve their QOL. Additionally, smoking, the use of other tobacco products, and hypercholesterolemia were associated with angina symptoms in patients with CAD.

Analysing malaria incidence at the small area level for developing a spatial decision support system: A case study in Kalaburagi, Karnataka, India

Spatial decision support systems have already proved their value in helping to reduce infectious diseases but to be effective they need to be designed to reflect local circumstances and local data availability. We report the first stage of a project to develop a spatial decision support system for infectious diseases for Karnataka State in India. The focus of this paper is on malaria incidence and we draw on small area data on new cases of malaria analysed in two-monthly time intervals over the period February 2012 to January 2016 for Kalaburagi taluk, a small area in Karnataka. We report the results of data mapping and cluster detection (identifying areas of excess risk) including evaluating the temporal persistence of excess risk and the local conditions with which high counts are statistically associated. We comment on how this work might feed into a practical spatial decision support system.

Factors Influencing Drivers' Left Turn Decisions

An experiment is reported which examined drivers' responses in turning left across a line of traffic as presented in a closed-loop, interactive, fixed-base driving simulator. Drivers were located near an intersection and instructed to turn left across a stream of on-coming traffic when they felt that it was safe for them to do so. The on-coming stream of traffic was varied in terms of the physical parameters of approach velocity, inter-vehicle time interval, and vehicle type. Specifically, seven velocities (10–70 mph) were crossed with seven gap sizes (3–9 sec) to yield forty-nine within-subject conditions for each of four, between-subject, vehicle types; motorcycle, compact car, large car, and delivery truck. There were ten subjects per vehicle type, giving forty total participants in the experiment. Results indicated differential acceptance of gap and velocity combinations depending upon the type of approaching vehicle. Collisions tended to occur along the boundaries where driver's decisions to reject or accept turns were ambivalent. They also occurred with greater frequency at higher velocity approach rates. Turn decisions were not dependent upon a single physical parameter such as vehicle velocity or inter-vehicle distance, although gap-size generated an arguable influence. Rather, left turn decisions appeared to result from the complex interplay of rate-of-change perceptual variables such as “time-to-contact” and the perceived characteristics of the vehicles themselves. Implications of the results are discussed with respect to the perception of vehicles and turn safety at roadway intersections.

Oral nifedipine versus intravenous labetalol for severe hypertension during pregnancy: a systematic review and meta-analysis

BACKGROUND

Oral nifedipine is recommended along with labetalol and hydralazine for treatment of severe hypertension during pregnancy by most authorities. Although nifedipine is cheap and easily administered, the usage pattern among health care providers suggests a strong preference for labetalol despite lack of evidence for the same.

OBJECTIVES

To determine the efficacy and safety of oral nifedipine for treatment of severe hypertension of pregnancy compared with intravenous labetalol.

SEARCH STRATEGY

We systematically searched for articles comparing oral nifedipine with intravenous labetalol for the treatment of severe hypertension during pregnancy in any language, over Medline, Cochrane Central Register of Clinical Trials and Google Scholar from inception till February 2014.

SELECTION CRITERIA

We included all RCTs that compared intravenous labetalol with oral nifedipine for treatment of severe hypertension during pregnancy, addressing relevant efficacy and safety outcomes.

DATA COLLECTION AND ANALYSIS

Eligible studies were reviewed, and data were extracted onto a standard form. We used Cochrane review manager software for quantitative analysis. Data were analysed using a fixed effect model.

MAIN RESULTS

The pooled analysis of seven trials (four from developing countries) consisting of 363 woman-infant pairs showed that oral nifedipine was associated with less risk of persistent hypertension (RR 0.42, 95% CI 0.18-0.96) and reported maternal side effects (RR 0.57, 95% CI 0.35-0.94). However, on sensitivity analysis the outcome 'persistent hypertension' was no longer significant. Other outcomes did not reach statistical significance.

CONCLUSION

Oral nifedipine is as efficacious and safe as intravenous labetalol and may have an edge in low resource settings.

TWEETABLE ABSTRACT

Although studies to date are few in number and small, nifedipine shows promise for severe hypertension in pregnancy.

Multiple cysts in kidneys: a case report

Von Hippel-Lindau (VHL) disease, which is an autosomal dominant inherited disease, is characterized by highly vascularized tumors in different organs. We report a 42-year-old male who presented to our hospital with diarrhea and weight loss of six months' duration. Ultrasonography of the abdomen revealed bilateral polycystic kidneys with multiple cystic and solid components as well as polycystic pancreas. A computerized tomography scan of the abdomen revealed bilateral multiple simple and complex renal cysts, cystic lesions in the head and body of the pancreas and a non-enhancing lesion in the left adrenal gland. The features raised the possibility of VHL syndrome and a biopsy of the kidney revealed atypical cells with a suspicion of malignancy. He underwent bilateral nephrectomy and is on maintenance dialysis since then.